﻿<%@ Page Title="" Language="C#" MasterPageFile="~/Templates/POS.master" AutoEventWireup="true" CodeFile="PatientAddEdit.aspx.cs" Inherits="Private_Patient_PatientAddEdit" %>

<%@ Register src="../../UserControls/DDLs/States.ascx" tagname="States" tagprefix="uc1" %>

<%@ Register src="../../UserControls/DDLs/Doctors.ascx" tagname="Doctors" tagprefix="uc2" %>

<asp:Content ID="Content1" ContentPlaceHolderID="head" Runat="Server">
    <style type="text/css">
        .style1
        {
            width: 99px;
        }
        .style2
        {
            width: 17px;
        }
        .style3
        {
            width: 121px;
        }
    </style>
</asp:Content>
<asp:Content ID="Content2" ContentPlaceHolderID="ContentPlaceHolder1" Runat="Server">
    <table>
        <tr>
            <td class="style3">Search:</td>
            <td>
                <asp:TextBox ID="txtSearchUser" runat="server"></asp:TextBox>
            </td>
        </tr>
        <tr>
            <td colspan="5"><hr /></td>
        </tr>
        <!--
        <tr>
            <td class="style3">Scan Drivers License</td>
            <td>
                <input type="button" id="btnScanCard" onclick="completeForm(this)" value="Scan" />
                <input type="button" id="btnCancel" onclick="cancelScan(this)" value="Cancel" style="visibility:hidden;" />
            </td>
        </tr>
        -->
        <tr>
            <td class="style3">First Name</td>
            <td><asp:TextBox ID="txtFirstName" runat="server"></asp:TextBox></td>
            <td class="style2">&nbsp;</td>
            <td class="style1">Last Name</td>
            <td><asp:TextBox ID="txtLastName" runat="server"></asp:TextBox></td>
        </tr>
        <tr>
            <td class="style3">Email Address</td>
            <td colspan="4"><asp:TextBox ID="txtEmail" runat="server" Width="250px"></asp:TextBox></td>
        </tr>
        <tr>
            <td class="style3">Address</td>
            <td colspan="4"><asp:TextBox ID="txtAddress" runat="server" Width="251px"></asp:TextBox></td>
        </tr>
        <tr>
            <td class="style3">Address (2)</td>
            <td colspan="4"><asp:TextBox ID="txtAddress2" runat="server" Width="247px"></asp:TextBox></td>
        </tr>
                    

        <tr>
            <td class="style3">City</td>
            <td><asp:TextBox ID="txtCity" runat="server"></asp:TextBox></td>
            <td class="style2">&nbsp;</td>
            <td colspan="2">State: 
                <uc1:States ID="ddlState" runat="server" />
                Zip:<asp:TextBox ID="txtZip" runat="server"></asp:TextBox> 
            </td>
        </tr>
        <tr>
            <td class="style3">Cell Phone</td>
            <td><asp:TextBox ID="txtCellPhone" runat="server"></asp:TextBox></td>
            <td class="style2">&nbsp;</td>
            <td class="style1">OK to SMS?</td>
            <td><asp:CheckBox ID="chkSMSCell" runat="server" /></td>
        </tr>
        <tr>
            <td class="style3">Home Phone</td>
            <td><asp:TextBox ID="txtHomePhone" runat="server"></asp:TextBox></td>
            <td class="style2">&nbsp;</td>
            <td class="style1">Other Phone</td>
            <td><asp:TextBox ID="txtOtherPhone" runat="server"></asp:TextBox></td>
        </tr>
        <tr>
            <td class="style3">Date of Birth</td>
            <td><asp:TextBox ID="txtDOB" runat="server"></asp:TextBox></td>
        </tr>
        <tr>
            <td class="style3">Date of PhD</td>
            <td><asp:TextBox ID="txtDocDate" runat="server"></asp:TextBox></td>
            <td class="style2">&nbsp;</td>
            <td colspan="2">Doctor:
                <uc2:Doctors ID="ddlDoctor" runat="server" />
            </td>
        </tr>
        <tr>
            <td class="style3">Prescription #</td>
            <td><asp:TextBox ID="txtPrescriptionNum" runat="server"></asp:TextBox></td>
            <td class="style2">&nbsp;</td>
            <td>Expiration Date</td>
            <td><asp:TextBox ID="txtPrescriptionExpiration" runat="server"></asp:TextBox></td>
        </tr>
        <tr>
            <td class="style3">Drivers License #</td>
            <td><asp:TextBox ID="txtDriversNumber" runat="server"></asp:TextBox></td>
            <td class="style2">&nbsp;</td>
            <td colspan="2">State:
                <uc1:States ID="ddlLicenseState" runat="server" />
            </td>
        </tr>
        <tr>
            <td><asp:Button ID="btnSave" runat="server" Text="Save" /></td>
        </tr>
        <tr>
            <td colspan="5"><hr />Files<hr /></td>
        </tr>
        <tr>
            <td colspan="5">
                <asp:GridView ID="gvFiles" runat="server" AutoGenerateColumns="false">
                    <Columns>
                        <asp:BoundField HeaderText="File Type" DataField="fileTypeDesc" />
                        <asp:TemplateField HeaderText="File Upload">
                            <ItemTemplate>
                                <asp:FileUpload ID="flUpload" runat="server" />
                            </ItemTemplate>
                        </asp:TemplateField>
                        <asp:TemplateField HeaderText="Save Update">
                            <ItemTemplate>
                                <asp:Button ID="btnSave" runat="server" Text="Save/Upload" />
                            </ItemTemplate>
                        </asp:TemplateField>
                    </Columns>
                </asp:GridView>
            </td>
        </tr>
    </table>
</asp:Content>

